Seasoning the Wok

I returned from Thailand seven days ago.  It seems longer than that and already like another world away (perhaps the nineteen air hours it took to get there contributed to that).  It was another world in many way, though. Warm and humid and sandy and tasty and sensual.  Massages to be touched.  Cooking class creations to taste and smell.  Elephant skin and warm coral filled water to feel.  Tonal language with unfamiliar rhythms to hear.  Blue salt water lagoons, green rice patties, pink dragon fruit to see.  Sensual paradise.  

And now I'm seasoning a wok I bought. Or trying.  They made the cooking look so easy in the class in the warm kitchen under the papaya tree with the garden out back.  Ingredients chosen expertly by the team from the fresh outdoor market, portions divided up, sauces mixed for us. All we had to do was chop and heat basically.  Even though heating did involve purposeful flames at one point.  I'm in between oil seasonings now.  The wok is cooling.  I have no idea if I'm doing this right.  The instructions in black and white don't have the color of the smoking oil coated pan included.  Even the internet pictures aren't helping much.

I'm thinking that our cooking instructor's guarantee for perfect Thai food is sounding better and better:  "Go to the night bazaar," pausing while she stirs her perfectly cut and beautiful vegetables, "Buy a big suitcase."  I'm wondering if there are secret ingredients to take back--something that will magically transform me into San Diego's best Thai amateur cook.  I stop stirring and look up.  "And take me back with you!  No visa required!"  A smile crosses her face as she cocks her head to the side, daring us kindly to laugh as she looks up and I hurry to start stirring again.  

"Four secrets to good Thai stir fry: 1) Thin wok, 2) High heat, 3) Fresh ingredients, 4) Small quantity," her words echo in my head as I'm back in my own country and dreading work the next day with an anxiety that has become ever more familiar but no less uncomfortable.  The woman at the Great News cooking store which is layered with aisles and aisles of shiny pots and pans, tiny overpriced mortars like the big one I carried back with me from Thailand, and coconut spoons with stickers and manufacturer information on them tells me about woks as I think about the difference between this clean well-stocked orderly store and the chaotic market with pots and pans hanging, knives out to examine, and coconut spoons made from tying the actual husk of the coconut to a stick.  No price tags, no labels.  Nothing shiny.  Questionably clean.  And the puppies with price tags on their head yipping nearby and the smell of fried and seasoned insects and ever present sticky rice on the hot wet breeze.  

The woman in the sterile cooking store tells me about their fancy woks made of some sort of conducting material that heats everything evenly but if you put it put them on high heat the expensive surfacing could bubble or crack.  I remember the four tenants of good stir fry and the woks we used in class--simple thin, dented steel affairs with a wooden handle which we held with three fingers as we tipped the oil closer to the gas flames just before we threw in the vegetables that went up in brief flames in an instant.  

I choose the thinnest wok, which still is shiny and comes with rubber long handle and a shorter one across which will preclude a repetition of the flaming stir fry even if we did have a gas stove.  She tells me I have to season it and that she will give me a hand out.  It doesn't sound so hard.  

I start to smell the stir fry as I place it and the wok brush (also well-labeled but at least wooden) in with my trunk full of food and large quantities of Costco purchases in the cloth bags I reuse.  A far cry again from the bustling crowded market full of fresh produce, more eggplants and mushrooms than I knew existed, fragrant spices and roots, and fish swimming in their version of a feed lot.  Costco is big and crowded but the high ceilings with artificial light don't recall the high grey blue sky over the jumble of canopies and make-shift roofs.  Our instructor tells us about the eggs (which they leave out) and rice (which is in different grades and prices) and eggplants (which are small and green) and roots (ginza, a relative of ginger) and encourages us to take picture of her as she is "so bootiful!"  People in Costco rarely make eye contact.

Granted, it is vacation, and therefore an immediate distance from the reality which pays for the fantasy, but still, I choose to take it for such in this moment, perhaps because that is what I need.

The entire time in Thailand, my head did not hurt, my joints did not ache, my ankles which were swollen from the plane ride over recovered effortlessly.  I remembered my pills in the mornings but not every night.  Otherwise, I didn't think about the lupus.  It was irrelevant.  

I did think about it again back in the States.  I wondered, as I have before, if I would be alive if I'd lived 100 years ago, or even if I lived now in Thailand where I doubt MRVs are as readily available.  If I had never taken the hormones which I think precipitated the clotting (to which I seemed to already have a strong disposition) would they have been avoided?  Or would pregnancy hormones have mimicked the same and sent me into fits of brain clots without which the MRV and heparin drip I likely would have stroked and died, perhaps with a baby inside of me.  I won't know.  I can only guess.  I know I'm here now and I still wonder.  And learn how to season a wok (I'm about to start round #4).

The knots in my neck and back melted away under the expert comfortable rhythm of the beach-side aloe or oil massages.  They tiny women would point to have us lay on our stomachs and start with the back, warming and rubbing up and down, untying the damp bathing suit top to make it a smooth plane for hand on back to touch, extending out to the upper arms briefly.  They'd finish there with a sideways loose karate-type chop which livened up the muscles and then would move to the legs, covering the butt with a small towel and leaning into the muscles that gradually released under the stabilizing but non-expectant pressure of her weight.  The legs were next.  She'd sit at the end of the bed near my feet and closest to the flat warm ocean and bend one up, then the other.  My calves were tight and painful on the first day at the beach.  By the last they were loose and pliable under her strong sure hands.  Rubbing my feet was one of my favorite parts.  Sometimes she'd hold pressure in one place on the sole of my foot and I'd feel the tension release from my neck or face or chest.  Just float away.  Even when she released the foot, the freedom from that small piece of anxiety stayed away.  

She karate chopped the legs, retied the back of my bathing suit and asked me to turn over, squirting the cooled aloe on my slightly sunburned belly with a momentary shock and I twitched and smiled and she smiled warmly back, chattering in Thai to the other women awaiting customers.  She'd put one hand on each of my hips and apply her weight, holding steadily, releasing the tension there out into nothingness where it could no longer hurt anyone.  She rubbed the front of my legs again and cupped her hand around my warmed and loosened calves rubbing repeatedly toward my feet.  My arms got more attention on this side as she rubbed the muscles of my forearms and stretched my  hands and snapped in a slip off the end of my fingers.  My middle finger almost always cracked gratefully.  Sometimes she'd rub aloe gently on my face.  With concluding chops, she'd ask me to sit up and rubbed my back and neck (the corporeal resting spot for the deepest of my worries).  Knots were left sometimes when she'd finish, but it was okay.  They would leave in their own time; I felt sure.  Maybe with the next touch, or the next banana pancake, or the next dive into the warm waters, or the realization of a long warm day ahead without expectations or responsibility, with people taking care of me and directing me and making decisions for me.  

This, too, has passed.

I finished my last day as a Children's Wards Senior today.  Last day with my own little team, teaching, rounding learning, orchestrating, helping, guiding, talking, listening, healing.  Ward months there are rough months, long days and longer call nights with the admit pager like a constant time-bomb on the pocket of my white coat next to the ridiculousness of my other TWO pagers on the outside of my pocket about which people comment at least three times per night, "Got enough pagers?"  I always offer to give them one or all three, but never had any takers.  Admit pages would flood in and I'd triage and delegate and strategize and examine and consult on sick surgery patients and review orders long after I'd sent the med students home or to bed and the rest to finish dictating.  Or sometimes not and we'd wander around the hospital.  I'd give them my ventilator talk, or my Peds in Pictures talk, sometimes a little Neurofibromatosis, or show them the x-rays of the patient I saw with rickets or with dermatomyofibrosis or go over line placement, or just how to read a chest x-ray.  

Being a senior, once you get beyond the terror, is really a bit of a high, especially at the beginning of the academic year with all new med students and interns and acting interns and this year even with new co-seniors.   I'd try to balance the admissions by work-load and learning-potential between the interns and med students.  I'd have the students read and give weekly presentations so they would learn about disease, we'd all learn from them, and the attendings would learn who they were. 

It is a small funny world at the Children's Hospital.  Loren told me the other day that I saved a patient's life.  Perhaps I did.  I was the one there; it was what any one of us would do.  It was what I try to teach my students and interns to do.  To learn what is sick and serious and to distinguish that from the other children who can wait until you save this one takes practice.  It always takes practice, but you get better.  I saw them get better this month.  I felt myself be better at my role, more comfortable in it and more confident, and more humble, more supporting. I felt proud of them and the growth they'd shown over the month.  I looked at my med students this month and remembered that five years ago this month was my own first ward month on pediatrics with two med-peds seniors, Dan and Dave, on my team and Jim as mine and Szilvie's intern.  I thought my seniors were geniuses.  I still don't think I'm as smart as they are, but things have completed a cycle.  My acting intern (fourth year med student) from this month is going into med-peds.   

I remember my first patient as a third year student.  Osteogenesis Imperfecta.  I read all about it.  I knew the kinds, I knew his kind, I knew very little about the arc of his care or disease, but I did what I could.  I got better.  Another patient that month had AIDS.  He was very sick, but they let him be my patient anyway.  I looked up his nutritional needs and his antiretrovirals.  He drew a picture one day and handed it to the team on rounds.  One of the seniors took it at first but my patient corrected him, saying it was for me, his "doctor." He's dead now, from complications of his disease.  I learned that during my fourth year in my Medicine and Literature class.  I still have that drawing somewhere.  I remember my first ER patient with tracheomalecia.  I remember the LPs we did on the children with febrile seizures.  

Now I supervised my interns doing lumbar punctures; they both did perfectly.  The med students learned to re-assure parents with a thorough physical exam. We all learned how to do better cardiac and neuro exams.  They learned how to befriend and not terrify the small children, and how to treat the teenagers with respect and firm boundaries simultaneously.  They learned to be excited about the patients and the healing and the learning and teaching we could share.  

I can't believe, not that it is over, that it actually is.  I started my first month as an intern there three years ago yesterday. Lost in the pink corridors with the round, triangle, or bowl shaped lights, sleeping in the daytime social work office turned call room by night (sleeping very rarely still), slow and worried and lost and nervous.  I'm a bit sad, actually.  Nostalgic.  Dr. Bradley says that means I was good at what I did; that that is a good sign.  I'll take that.  

Residency is a long, long, grueling training path and yet it is also a precious time of camaraderie and learning that cannot be duplicated.  I'll miss the time and the team and the trial by long sleepless nights.  I'll miss the dull lull of energy and personal temperature disregulation at 4am (that only a little).  I'll miss the emergency chocolate pudding and grahm cracker snack at 3 am because I missed the cafeteria closing.  I'll miss my interns and med students.  I'll miss chaos of the morning pass offs at the end of the call which precede the drive home and the comatose sleep.  I'll miss the daily teaching and noon conferences and morning report and EBM.  All of the things that seemed so time-consuming and arduous when I started now seem like old friends.  

I don't know if that's good or bad, that it sounds like I have just written my wedding vows to a job I have been dating constantly for three years when we are doomed to separation in another year.  I guess I've only ever been good at serial monogamy anyway.  

Out of this World

I'm on MOD-2 for 13 shifts, and in the middle of my fourth shift--they run from 8pm to 8am--and reminded of a bumper sticker I saw last year which I am modifying for this rotation: "Worst. Rotation. Ever."

But, that is not the entire reason I'm writing now (from work in the hour and a half before I start admitting from the ER). The reason I'm writing now is because the supposed "lupus cerebritis" (but really psychotic) new admit needed a lumbar puncture and I was helping Charlene (my intern from the ICU last month) while her supervising resident admitted another patient with her other intern. Seemed normal enough. To start.

Charlene tried the lumbar puncture a couple times, as I'm standing there all gowned up in our sterile blue garb. Of course I had to find an extra head cover because the patient wanted the one in the sterile kit (first clue of impending crazy?). She asked me if I could try next. I sterilly move the table out of the way, the bed was high up in the air so I didn't have to bend over as much; I re-evaluate the landmarks and re-direct the needle to try to slide it in between the vertebrae to get the cerebral spinal fluid. I hit bone and redirect again.

During this time, I reassure the patient that she is doing well. She is courteous and says, "thank you." Then the tenor of her conversation changed, "I have to go. We're going to be late for the party. It's 11pm and we need to go. You need to finish this procedure." I'm trying to concentrate on getting the fluid, and reassure her and ask her to stay still and remind her she has a needle in her back. And then she says, "I'm leaving. I'm going to go." In the split second while I try to decide if she's serious, she sits up and begins grabbing her personal items. I pull the needle out of her back just in the nick of time. Blood starts streaming down her back where it had been jostled by her movement. Fortunately, she wears only the blue bouffant cap, an untied hospital gown, and Depends (which catch the dripping blood), so her clothes are spared.

When she grabs her stuff, she also grabs Charlene's white coat and pulls out Charlene's phone, books and papers from that night's work out of the pockets. "Ma'am, that is my coat," Charlene is calmly reminding her as the patient yanks it back toward herself, "No it isn't! It's mine. I bought it." The nurses threaten to call security and try to reason with her (though she's entirely unreasonable). She's out of bed now and Charlene tries to pull her coat from her and they struggle back and forth in the 6-bed hospital room. Then the patient takes a swing at her, gouging Charlene's hand with her finger nails, and Charlene lets go of the coat.

She storms out of the room muttering nonsense as her 72 year old mother gets out of the way (she's been through this before and sometimes has to lock herself in her car when her 40 year old daughter gets out of hand at home). With blood dripping down her back making a red stain on her white Depends, she makes a bee-line for the elevator. "Someone has to stop her," her mother says defeatedly as we stand there and watch her go, afraid to get into an altercation with her.

Security comes up the other set of elevators after she's already taken the main elevators down, "What's going on?" they ask a little late. We explain. "Is she on a hold?" This means has psych or the ED placed a "psych hold" on her meaning that we can hold her against her will for the protection of herself or others. She is not on a hold. Yet. We page psych and the ER to see who can place one on her fastest and send security after her.

Then we wait.

We wait.

Where is she?

Her mom is concerned, but calm. Charlene wants her coat back. We bandage up her wounds. I'm still a little stunned and ask Charlene how badly her team wanted this LP. Not bad enough to try again. We order haldol to have on hold for when (if?) she is returned.

She is. Three security guards escort her down the hall (now in a wheelchair), still clutching her personal belongings and Charlene's white coat. They tell us they found her at the outpatient clinic a block away and mention that she had blood dripping down her back. They also come up to Charlene and tell her the patient had her badge also, in a somewhat accusatory tone.

The patient has calmed down, apologizing even, but making no sense, "How do they get her into the galactaca when it is all round without windows?" And when we asked her if we could put a bandage on her back, she said, "No, I'm just going to let it bleed for a while." And then when she's all tucked back into bed, she asks, "What does combative mean?"

Charlene's got it under control for now. I return upstairs to relate the saga to the rest of the on-call team and Mark, the night float intern, and continue coveting a root beer float until the cafeteria opens at 11:30 pm. Mark says I should have taken pictures during the coat tug-of-war. He's even willing to reenact it with Charlene. But we settle for a computer stick figure picture for the time being.

O O
{ X ]
/\ /\

1123

The next day he was still alive, but barely. Barely. They'd moved him up to the 11th floor and something told me right away that he would be in the room I'd been in two years prior.

He was. I learned that his housekeeper and her daughter had come to see him that night after I'd left. She held his and and said his name, disbelievingly.

I went to see him upstairs. He was no longer responsive at all. He breathed a scant 8 times her minute with his mouth gaping open and his body arching back with each painfully deep breath. He's alone in the room. The view is the same as I stared at for days and day. The pictures are the same. No flowers for him, where I had several bunches. They've taken the night stand out, also. He has no need for it.

His bag of personal items in on the chair next to the bed. His wallet is there. I look at his drivers' license picture and he looks sad in it. Healthier, but still sad. He has the card with the mortuary on it. He's made all the arrangements and written on the back the phone number "to call in case of my death." It made me feel a little more at peace that he'd done that, for some reason. He wanted his housekeeper to have his valuables. He had a few rings and bracelets that he must have been wearing when he was brought in originally. His clothes were old, but clean and neat.

He felt warm when I held his hand again.

I went back downstairs to the rest of our sick patients. We rounded on them and saved him for last. By the time, the intern, fellow, and I got there, I looked at him from the door. No more of the gasping breaths. No more breaths. "He's gone," I said.

We walked in. I took his hand. He was still warm. Charlene pronounced his time of death. Tears rolled down my cheeks and she asked if I was okay, "It's just sad." Just sad.

Not Forgotten

He's probably dying right now.  He was breathing in the teens--comfortably for the first time in days and the morphine drip had been turned up to 10.  They said he was unresponsive but when I went in to hold his hand and say his name and tell him to relax and everything was okay, he opened his eyes.  I stood with him for a while, watching out the window, thinking how sad it is to die alone.  They only person he had was his housekeeper and he didn't want us to call her.  When Julie, the nurse, tried anyway, no one answered.  He was breathing with a face mask now.  He'd been grumpy since I'd admitted him a week before.  At first he had a head bleed from taking too much coumadin (or at least his INR was too high at 9.8) and had bled into an unusual spot in his head that neurology thought might be a metastases from an undiscovered cancer.  I went in to visit him even after I'd transferred him to the neurology service.  Once day I went in and he was sitting at the side of his bed with his head bent down over his bedside table.  I said hello and asked him how he was feeling.  He told me to wait a minute.  I thought he had questions for his medical team so I told him I was only visiting now and the neurologists were his doctors.  "Just wait a minute.  We can talk."  I felt bad.  He'd only wanted company, which is what I wanted to be, but I didn't understand.  He didn't really have much to say.  I stood there and held his hand for a minute before he shooed me off, "Okay, you can go now.  I'm going to meditate."  

Ali surprised me with a visit on that first night when I admitted him with the head bleed. He was sitting outside the room after I visited Mr. M. and he'd curtly dismissed me, telling me he wanted to sleep.  Mr. M. was grumpy.  He wanted to be left alone, "I'm fine!"  He softened up a little.  He'd been having trouble breathing for at least a month, he told me, but today he had weakness on his face that was new--"heaviness actually."  He came in because he was worried he'd had a stroke.  When the head bleed showed up on the CT and his INR came back at 9.8, likely from taking too much coumadin, a grilled him about his diet and his activities.  He didn't shop.  He didn't eat well.  That last month he could barely walk around his apartment without getting short of breath.  He'd been to the coumadin clinic 1 month before and always on time for the past three years and his INR has always been in the right range--until now.  

It wasn't until a couple nights later when Ali and I started talking some how about how many older people who are lonely commit suicide by either taking too many pills or exacerbating their medical conditions on purpose that I wondered if Mr. M. had done that.  He insisted to me that he'd taken the right amount, recited his doses to me correctly and everything, "Five on weekday and seven mg on Sundays."  He looked irritated and disheartened when I told him I thought it was the medicine that had done this to him.  He seemed shocked.  

When I first saw him in the ER he didn't even want to talk to me because so many people had already asked him a million questions.  I told him I'd wait and we could see him upstairs.  The neurosurgeons wanted "neuro checks" every hour all night.  Wake up, open your eyes, have a bright light shone in both of them, move your hands and feet.  Go back to sleep and repeat every hour.  (I remembered my neuro checks every four hours when I was a patient and even that was horrible.   Every single hour.  There's no way he slept much those first few days he was there.)  I asked him if he felt depressed.  He did.  He lived alone and had no family.  Had been married once, but wasn't now and didn't seem to want to talk about it so I dropped the subject.  Had no children.  

He did fine in the ICU and I transferred him out the next day.  I almost sent him to the medicine team, but on second thought I figured it should be neurology to watch over him since his head bleed and his new kepra dosing was his main concern.  Though he had so many medical problems that I knew they couldn't handle well that I hesitated.  His COPD was "end stage" with an FEV1 of 1.47.  His heart failure on his new echocardiogram had progressed to "severe diastolic disease."  His atrial fibrillation was uncontrolled since we'd stopped his medicine for it because of his new low blood pressure.  His coronary artery disease had necessitated a coronary artery bypass graft a few years before.  His legs were almost black from decreased blood flow related to his peripheral vascular disease.  His chronic kidney disease had acute kidney injury stacked on top of it since he hadn't been eating or drinking well and since his volume status was a fine balancing act with his heart barely able to pump any more.  

On the neurology service, they started him on an antidepressant and got a medicine consult to follow him (unfortunately not one of our most stellar attendings was on consults at that time).  They didn't restart his home medications and they gave him more fluid than his heart could handle so a lot of in ended up in his lungs, making it harder and harder for him to breath.  He may also have been aspirating some of his food and developed pneumonia in the interim.  

He transferred off our service after about 12 hours and out of the ICU the next morning.  I had the next day off but was worried about him so followed along as much as I could on the computer from home.  After a couple days I didn't hear about him until one of the traveling nurses who worked in the ICU also came to find me since neither the neuro intern nor attending had paged her back for three hours, during which time she'd called a rapid response o him because he was working terribly hard to breath and his PO2 on his blood gas was 45 and he was in afib and tachycardic and hypotensive.  She came to find me just as I was having anesthesia intubate another patient in the other step-d0wn unit, "Can you come see Mr. M.?  I can't get in touch with his team."  He looked terrible when I got there.  I ordered a few things and then asked him if he remembered me and how he was feeling.  He remembered me, and though his breathing was very labored he said he felt fine, in very short sentences.  

I paged the neuro intern again, signing it "ICU resident" and he called back at last.  When I told him how sick his patient was he said he'd be there in 10 minutes--and he'd called from an outside line though he was supposed to be in house.  My worry for Mr. M. mixed with my irritation about the lack of recognition about how sick and fragile he was.  I told him what to do and cleared a bed for Mr. M. in the ICU again (the same bed he'd had before--the one with an ocean view where you could see downtown and the airplanes fly in and out).  But the neuro intern didn't say anything about moving him.  I called him shortly after and got a little more stern, saying that he at least needed to let his attending know how sick he is and strongly suggesting that he be trasnferred to at least a medicine team and probably back to the ICU (me).  "Oh. Okay.  Yeah.  Thanks.  Sure.  I'll call him."  I'm sure they do a much better job with all the stuff above the neck than I do, but at the very least he needed to know when to ask for help.  And though I very rarely make a fuss, I fussed at him quite a bit about needing to respond to pages and recognize when his patients get much worse.  

Soon after I got a page saying his attending "would be happy to transfer him to wherever I thought most appropriate."  Good thing since I'd all but finished the transfer orders already. 

That whole night, I tried not to intubate him.  His COPD was so bad I thought he'd never get off the ventilator if I put him on it.  He didn't want the BiPAP mask (though he agreed to it by the next morning) so we fiddled around with face masks and nonrebreathers and oximeters and the like.  I diuresed all the extra fluid I could off of him with a bumex drip and diuril.  I controlled his out of control heart rate with a continuous infusion of a diltiazem, a rate controlling medication.  His blood gas didn't get better, but it didn't get worse either.  The fellow that night gave him a 50/50 chance of being intubated by morning.  We made it through the night, though. 

When I went to say bye to him that morning, I told him I had the next day off but would be back on Wednesday (today) and that I wanted to see him without a tube down his throat.  

He was already telling the nurses every morning, "I'm going to die today."  Of course yesterday he said it more non-chalantly.  Today he was more serious.

One of the interns was going to round on him this morning, but I told him I wanted to instead.  He looked no better, but also no worse.  He still worked hard to breath and that couldn't last forever.  We decided to put an arterial line in him on rounds and by the time we got around to doing it, the results were terrible, pH had gone from 7.37 to 7.19.  Not good.  And while he'd been more of his cantankerous self the day before and even this morning, he was no longer saying he felt fine.  "How's your breathing, Raymond?"  "Not so good," he gasped.  

Neal, the intern, talked to him about wanted a tube to help him breath.  He shook his head, "no," no longer able to talk much for lack of breath.  "Do you understand that you might die without one?"  He nodded.  "Open your eyes, Raymond!  I need to make sure you understand this."  And he repeated the same questions in different phrases.  The answers were the same.  My eyes welled up as suddenly I flashed into his acidotic mind and wondered how it would feel to have someone ask you if you understood that you probably would die--very soon. And die without anyone except people you'd met seven days ago.  Like your life had been a blip on a screen that was about to go out and no one would even remember you.  No one, except perhaps your cleaning lady and her daughter, would even know that you were gone.  And who knows if they would care.

The day before he'd met with social work and had been very anxious about being able to pay his rent by June 1st or he would lose his apartment.  He also worried that if he died his cleaning lady, Rosarita, had only three days to clean out what she wanted from his apartment where he's lived alone for 15 years, before everything else went to the Salvation Army.  He'd fretted about it since before he transferred back to the ICU.  On the day when the nurse came to tell me he was breathing so badly, she told me he'd made her look in his wallet and get the card for a mortuary that he carried there.  And get the card for his house-keeper to tell her to make sure to clean out his apartment within three days of his death.  

It was as if his life would just blow away with the ocean breeze, as if he'd rustled around with the leaves for a few days and then...gone.  Nothing left.  Things he'd known and recognized and used daily given away.  Maybe items he's saved or treasured left without stories or context or care, with no one to remember or know.  

I wondered what he thought as he drifted off into that morphine-induced haze as I held his hand and stroked his hair and tried to imagine what his life might have been like, or what he'd wanted it to be like.  If he'd had regrets.  If he'd pictured his end differently.  If there was someone he'd love who he wished were there instead of me.  He still opened his eyes when I called his name, "Raymond," the muscles above his eyes flickered and his eyelids rolled slowly up and his eyes moved to focus on me briefly, "It's me.  Everything is okay.  You're doing great.  Just relax now."  That morning he'd told us he was fine and that he needed a shave and a haircut.  It was hard to understand him through the mask and he'd had to repeat the "shave" part a few times and got irritated.  

I looked at his salt and pepper stubble under the oxygen mask and wished we could shave him while he still had any connection with this world.  Julie rubbed his face with a warm washcloth over his eye lids and his forehead and his hair and his dry lips sucking in numbered breaths.  The scar across his chest reminded me of his CABG a few years before and I wondered who had helped him recover from that.  Or who had gotten him to his coumadin appointments or to his doctor's appointment with one of my co-residents.  I remembered Pop had had a CABG too, and I'd come home to take care of him.  My hands were colder than Raymond's, but I knew they wouldn't be for long.  I squeezed his hand and rubbed his shoulder and looked at the liquid drip into his veins.  His arterial line was oozing and when I moved my hand away there was a puddle of serous fluid in his palm.  I was surprised each time I returned and his hands felt so warm.  

His heart rate had slowed way down, despite us turning off both rate-controlling medications. His blood pressure was low again.  His O2 sat was 92%.  I watched his heart monitor flutter around 66-62-60-58-59-58-57.  When you don't get enough oxygen and your most recent blood gas shows that your pH is 7.10, your heart doesn't work well.  Your body is tired.

I remember now what I said at Pop's service, that he was tired and it was time.  

And maybe it is time.  I fretted and went back and forth with his intubation with the attending earlier, knowing that I could convince him to get the tube in in throat and that on the ventilator I could fix his blood gas. But I couldn't fix his lung disease, or his heart disease, or his kidney disease, or his loneliness.  The most I could do was prolong this inevitable thing that may have taken him even as I have been writing.  And he may do to a nursing home or a "rehab" facility which the fellow, who did moonlighting there, said was "a fate worse than death."  I knew Raymond was tired, too, and that he felt tired, and sad, and frustrated and alone.  I supposed he was ready, "Do you understand that you might die?" Neal yelled at him as we tend to do with those who are very sick.  He nodded.  

I fought back tears as I held his hand and looked out his window, thinking of my med student's patient who had died a couple years before at the VA and her asking me if I'd been there when he died.  I hadn't.  The nurses called when he was almost gone, but I didn't want to see the end and he'd been in a coma all day.  

All I could do now for Raymond was bear witness to his candle flickering out.  I could make him comfotable so his last breaths weren't agonal.  I went to the bathroom and came back to say goodbye to him, "Just relax," his eyes flickered again and I placed my other hand over his heart feeling it beat, still warm, in his scared chest, "Everything is okay.  I'll see you soon.  You're doing great." I squeezed his hand and asked Julie, who was now doing her charting in his room instead of outside where the nurses usually sat to keep his respiratory rate below 30--to keep him comfortable.  She said she'd thought he would go faster once we'd started the morphine drip, but she wanted to not let him die alone.

As I waited to talk to her before I left, they moved his 84 year old neighbor out in a body bag.  He'd come in the night before after being found on the floor of his apartment covered in flies and feces when the management came in to see if the fire alarm was still working--so dehydrated his tongue was retracted back into his throat.  His leg was dead with dry gangrene and by the morning when I came in his arm, too, was cold and pulseless.  And while he'd been report-ably able to nod appropriately in the ER, he was no longer waking up at all even though we'd turned off the sedation hours before.  I cringe to think that his last days were spent alone on the floor of his apartment like that.  I cringe and I cry.  I'd tried to find any family or friends of his that morning, but he'd only listed the security guard at the place where he had lived five years ago, a man who remembered him but had only had casual small conversations with him and knew of no family or friends.  Every year after that when he'd renewed his lease, his apartment manager had said he'd left that line on the form blank.  "No family or emergency contacts listed."  Not a single soul to call or care or even know that he's gone.  No one to claim the body.  No one to know.  

Perhaps they have both touched people in their lives who will remember them.  Perhaps Raymond was grouchy always and drove people away.  Perhaps the other patient, who his landlady called, "a sweet man," did not remember those last horrible days, but some good day.  Maybe a day he spent in the woods or at the beach with someone he once loved.  Or maybe a day spent alone but with that unreasonable happiness that has no explanation except that it is.  Maybe Raymond is glad he is not dying alone.  Maybe he's glad to be going.  And maybe he's going somewhere more hopeful where he can breath easily and his heart can beat strong again and he can walk on feet that done constantly ache.  My fellow said she doesn't know how people can do this job without some sort of belief in a higher power and some place after.  

I don't always know what I believe, but as I placed my hand over his heart and said goodbye, I said to myself, "May God bless you and keep you."  May he indeed.  In a way that mankind has not blessed or kept you.  And in a way you have not been able, perhaps to bless and keep yourself.  

When Raymond came in that first night, grouchy as ever, I'd asked him what he liked to do and if he had any friends.  "No, I don't talk to people much.  I'm a thinker.  I like to think.  I like plays and opera.  I'm deep.  I never finished more than eighth grade, but I like real conversation.  I don't watch that trashy TV.  I read books."  I pictured him then in his apartment, alone, thinking about ideas he didn't or couldn't express.  I wondered how he'd watched opera or if he really had or just wanted to.  "I'm deep!" he'd insisted to me, as if he still has something to prove.  

But he had no more time to prove anything.  Or maybe he did.  Maybe that it really was his time to die, and those cards he carried around in his wallet and his worry about his house-keeper cleaning out his apartment said that he was ready.  Maybe he proved again to me that sometimes it is okay to go.  Maybe even that it is okay to go alone, if that's what you want.  Maybe that this grief of his solitude that we have imposed on him is akin to the pity he disdained.  Yet, still I believe that holding his hand and a wet washcloth on his face and a stroke of his hair felt good,  and felt like someone on this earth cared enough to make it okay for him to go on to the next.  

All he'd wanted to eat on his meal tray the day before was the vanilla pudding.  Julie said he'd scarfed it down.  Today we got him more vanilla pudding.  It was all he wanted to eat.   That and a milkshake.  Two puddings and an Ensure (the closest we could find) sat unfinished on his bedside table.

You see, Raymond, you are not forgotten.  Now at least someone will remember that you liked vanilla pudding.  And that you liked opera.  And that you meditated.  And that you liked to think.  And that you were tired and ready to move on.  I may not know your whole life, except what I imagine, but these things I know.  You are not forgotten.  Even as I picture you barking, "Forget me!  Leave me alone.  That's what I want." 

Is it?

Expiring

"Doctor, I do have one more question:  Can I kiss her?"  He asked the intern as I stood off to the side.  Neither of us had ever met this strong and kind-appearing man in jeans and a brown plaid shirt.  We'd only spoken with him on the phone several times that night.  Each time with worse news.  Matt, a bright and kind intern, had called him to consent for an arterial line when her blood pressure was dropping into the realm of other worlds.  He'd spoken with him about his wife's state.  He'd done everything he could with the two small peripheral intravenous catheters that he could.  He'd called me when she needed intravenous medications to keep her blood circulating.  Medications that usually have to run through a more invasive central venous line--medications you only can use in the ICU.  

I'd met her two days before.  But she'd died two months before I'd met her I later discovered as I read through her records.  Six months before she'd gone in for surgery to replace both of her knee joints due to severe arthritis.  One became infected and they tried antibiotics.  A lot of antibiotics.  Some of which she was, as it now seemed, deathly allergic to.  She got a rare condition in which the top layers of skin separate from those beneath.  She had "toxic epidermal necrolysis" over 90% of her body.  

Your skin is your largest and possibly most important organ in your body.  It keeps in what needs to be in and it keeps out what needs to stay out.  They'd taught us that in medical school.  And the woman I met two days before proved it to be true.  

In the time since she'd developed TENS, she had undergone multiple rounds of bacteria in her blood and low blood pressure and months of ICU care and central venous catheters to deliver more antibiotics and blood pressure medications.  Then her kidneys failed from one of her episodes of low blood flow and she stopped making urine and needed a larger central catheter to be on dialysis.  These catheters got infected along with her blood.  The bacteria that she started growing in her body became resistant to all but the strongest and newest antibiotics that we have.  Then on February 2nd, she'd died.  

She went into cardiopulmonary arrest, or as we say, she "coded," necessitating extreme measures to resuscitate her.  And the resuscitation worked in the sense that her heart restarted and her brain kept the centers that told her body to breath.  But the rest of her brain was gone, having suffered massive strokes as a result of the intervention.  It was like the little babies I'd see who don't get enough air to their brain when they're born.  Sometimes they live for years, but they only know to breath reflexively.

Her skin was the color of a severe sunburn.  And it sloughed off wherever tape or catheters were attached, and even in several places where nothing was attached.  Her hair had almost completely fallen out; what was left was in greasy curly wisps across her scalp.  She was swollen from what I imagine were high doses of steroids to keep her body from attacking its skin and from the large quantities of fluid we'd given her to keep her alive those last few days.  She smelled of infection and we put on the yellow "contact precaution" gowns when we went into her room, not wanted to transmit her infections to ourselves or our other weakened patients. 

That night when we were losing her blood pressure, I called her husband and told him we would need to start medications to keep her blood pressure going.  It was the first time I'd spoken with him but I knew from the chart that he'd had several conversations over the last months about his wife's state of health and her impending death.  The next days he'd planned on moving her to a hospice facility so she could die comfortably.  

To preserve her live that night what I really needed was a large central line--one for pressors and dialysis.  It would be difficult to get on her and it would be painful.  He didn't want to keep trying to perpetuate what remained of her life, however.  I supposed that I could try peripheral pressors, which don't take long to burn through veins and cause longer-term complications which I knew would not be an issue with her.  She was out of "long term" on this earth.  

I offered that to him, only wanting her to make it five more hours to 8 am when she could go to hospice and die comfortably.  I suspected, though, that she would not make it that long.  And I knew she wouldn't unless I gave her those medications. 

It had taken him months to come to terms with the fact that she was going to die and finally, he was ready to let her go.  But I didn't think I could keep her alive much longer.  He'd only recently changed her "code status" to exclude compressions and shocks (she'd had a tracheostomy tube placed months before).  But he said we could still use code medications, which are temporizing at best without the other interventions.  

So I started a pressor peripherally; and it worked for a while, but then we were using as much of it as we could and her blood pressure was still falling.  She started to die at 6 am and I went for the "chemical code," which ended up feeling futile as we stood around her in our yellow mourning dresses and injected epinephrine into her small peripheral lines which made her blood pressure temporarily jump to 210/150 and then trickle back down to 70/30 and keep falling.  I asked the nurses to call her husband as soon as we'd started and fifteen minutes into the code I called him myself from the room.  We'd talked several times by then and I knew he lived far away and had just gotten out of the shower and was planning on being there at 8:30.  We weren't going to last that long. He said it would take him 45 minutes to get there, "depending on traffic," he told me in a steady voice.  I begged him to please drive carefully, unable to truly imagine what he'd gone through those last several months.

I started another intravenous infusion to keep her blood pressure in the alive range until he got there and the nurses needed to give her boluses of epinephrine even with that.  They paged me when he arrived.  

By the time I got down to her bedside, Matt was already there explaining things to him and asking him to put on the yellow gown.  He did a god job--calm and sensitive and thorough.  He'll be a fine doctor.  I stayed back, not wanting to complicate matters more with one more face.  And, not wanting to see the pain in his stoic eyes any closer than I already had.  

He asked Matt if he could kiss her and Matt said yes.  

In the room, he spoke softly to her, telling her he'd tried everything he could to keep her alive, but now it was time to go.  Now she could go.  He kissed her red swollen mouth as her eyes roved purposely around the room.  I don't know what she felt those last moments, if anything.  He asked us to turn off the pressors and start a morphine infusion to ease her pain and calm her labored breathing.  He stayed at her bedside, whispering to her for the next few hours in took for her heart to stop its resilient beats.  

The social work note said her children found it too hard to see her like that.  A family friend was there with him for part of the time.  The social worker himself stayed for much of her slipping away, comforting and listening to her husband.  In his note he said they'd talked of God.  The note ended with him dictating, "I have just been informed that the patient is expiring at this time."  Time of death 2pm.

Ali had been working that night and tears were welling up in my eyes when I got back from the SICU to our medical ICU.  I knew it was time for her to no longer suffer, but her husband was so "dear" with her, as one of the nurses who'd helped code her said.  And soon she would be gone.  Plus I'd been up all night and hadn't eaten since lunch the day before trying to admit two other patients and keep her alive a little longer. I felt wrung out.  He kissed me before he left for breakfast.  I still had to present the patients I'd admitted and finish rounding.  

In debriefing the chemical code issue with the ICU fellow, she told me she didn't even offer pressors through a peripheral line, nor offer purely chemical codes.  They had no long term benefit.  The code had felt ridiculous from a medical standpoint.  I knew it could only end one way and we were simply delaying the inevitable and quickly approaching end.  

But sometimes, maybe delaying is enough.  It made no difference to the patient, who I still believe had spiritually left months ago.  But it made a difference to her husband--he was able to be at her side when she "passed."  He'd told me he wanted to be there.  I didn't stave off death for the dying, but for the living, for them to say goodbye in whatever way they needed.  

It was a hard code for me, really the first I'd "run" alone--long and immediately unsatisfying in its outcome.  But now, days later, as I talked it over with another of our interns, I think I would do the same if I had it to do again, though perhaps ask her husband to come in sooner.  I'd still keep her alive until he got there, if I could.  It's the least I could do.

I think if him hunched over her bed, holding her hand and kissing her face, whispering soothingly in her ear.  Maybe she was there.  Even if she wasn't it was  testament to what she'd been, and what they'd been together.  And what he would have to be without her. 

Death is not a fight we win or lose, though it sometimes feels that way.  And it's hard to meet the end of the known--and hard to send those we love, those with whom we thought we'd grow old, those with whom we'd shared a life off into the unknown away from us and alone.

I wonder if radiologists see people in black and white.